| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,638 |
2,636 |
$140K |
| D0140 |
Limited oral evaluation - problem focused |
2,095 |
2,060 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
3,077 |
3,076 |
$87K |
| D4341 |
|
470 |
160 |
$76K |
| D0274 |
Bitewings - four radiographic images |
2,152 |
2,150 |
$75K |
| D1120 |
Prophylaxis - child |
1,247 |
1,247 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,719 |
1,719 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
307 |
174 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
2,343 |
2,302 |
$40K |
| D2740 |
Crown - porcelain/ceramic |
45 |
27 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
449 |
449 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,539 |
1,468 |
$15K |
| D2950 |
|
68 |
56 |
$13K |
| D4910 |
|
60 |
60 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
14 |
$3K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$325.00 |